Applying for Access Access Services - Applying for Access In-person Evaluation Required Submitting The Application Other Transportation ...
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Access Services
Applying for Access
> Applying for Access
> In-person Evaluation Required
> Submitting The Application
> Other Transportation ResourcesApplying for Access Access provides free transportation to
An in-person evaluation is required to and from your in-person evaluation.
determine your eligibility with Access Applicants also have the option to
Services. In order to ensure that Access has provide their own transportation.
the necessary information to process your
application, complete the following steps: Required In-person Evaluation
> A photo will be taken. We will ask to
Access Rider ID number is required. remove articles that obscure your face.
If you do not have an Access ID Number, > If applicable, bring your primary
please contact Customer Service mobility device that you intend to
at 1.800.827.0829 (TDD 1.800.827.1359) use while out in the community.
or visit eligibility.accessla.org to have one > If you need assistance, please bring a
issued (application will not be processed personal care assistant (PCA).
if ID number is missing). > Bring a valid photo ID. Access
accepts the following form(s) of
1 Complete and mail the application photo ID (required):
portion in the enclosed envelope to: a. State issued Driver’s License or ID
Access Eligibility Center b. Military ID
5747 Rickenbacker Rd c. U.S. Passport
Commerce, CA 90040 or via email d. LACTOA Reduced Fare ID card
to: EligDept@accessla.org e. Other transit operator reduced
If you have other questions related fare ID card
to the application or need assistance, > Children under 18 years of age:
filling out the form, please call a. School ID
1.800.827.0829 (TDD 1.800.827.1359). b. Birth Certificate with parent’s
photo ID
2 Allow seven (7) calendar days > Bring any documentation that
after you send in your application will support the information in
form to call the Access Eligibility your application (optional).
Scheduling Center. > Eligibility is based on your functional
abilities to use fixed route bus or
3 Schedule your in-person evaluation at train services.
626.532.1616 (TDD 626.532.1620), > The evaluation will include an
Monday through Friday from interview as well as a functional and/
8am-5pm. Please do not call before or a cognitive evaluation, if necessary.
the seven (7) calendar day period. The Evaluator will be looking at yourfunctional skills which are needed Other Transportation Resources
to ride buses and trains. Los Angeles County has fixed route
> If the Evaluator needs verification bus and train services that are equipped
from your healthcare professional, with ADA accessible features such
they will contact them. as lifts or ramps, securement spaces,
designated priority seating, stop
The application process will be announcements, audio announcements,
considered complete with the following: handrails, lighting, and operators
a. Completed application including who are trained to assist passengers
a copy of your photo ID with disabilities. These modes of
b. Completed in-person evaluation transportation do not require
c. Completed healthcare professional prior reservation.
verification (if applicable)
You will receive a letter within 21 days For more information about bus and
after the completion of the application train routes, schedules, and/or reduced
process informing you of your fares in Los Angeles County, please
eligibility status. visit metro.net or call 323.GO.METRO
(323.466.3876). Riders with hearing
This application is available in alternative or speech impairments can use the
formats. If you require an accessible California Relay Service. Dial 711 and
format of this application, please the number you need.
contact Access Customer Service:
1.800.827.0829 (TDD 1.800.827.1359) Access can assist with your search for
between the hours of 8am and 5pm transportation options including Travel
Monday through Friday. Training which provides assistance with
learning how to use the fixed route bus
If you have a concern about what or train services. For more information
information you need or what to do to call Access Customer Service at
prepare, the Disability Rights Education 1.800.827.0829 (TDD 1.800.827.1359)
and Defense Fund (DREDF) has or visit accessla.org.
published “ADA Paratransit Eligibility:
How To Make Your Case.” You can get Questions? Please call
a copy of this helpful guide online at Customer Service:
dredf.org or by calling Access Customer 1.800.827.0829
Service Center at 1.800.827.0829 (TDD 1.800.827.1359)
(TDD 1.800.827.1359).In-person Evaluation Application
1 Personal Information
Access ID number (6 or 7-digit number)
Access ID number required:
To request an ID number, please call
*Application will not be processed without ID#. Customer Service at 1.800.827.0829
or visit eligibility.accessla.org.
Last name
First name MI
Medi-Cal ID number (optional):
I do not have a
Medi-Cal number
Applicant’s primary language (if other than English)
Date of birth Gender: Male Female Non-binary
Home street address Apt number
City State Zip
Mailing address (if different from your home address) Apt number
City State Zip
Primary phone number Alternate phone number
Cell TDD Cell TDD
Email
1
Access Services accessla.org2 Emergency Contact
Name Relationship to applicant
Primary phone number Alternate phone number
3 Current Use of Public Transportation
When was the last time you rode the fixed route bus or train independently?
How frequently do you ride the fixed route bus or train?
Daily Weekly Monthly Not currently using Never used
What is the farthest that you can travel outdoors without the help of another
person (using mobility device/aid, if applicable)?
Less than 1 block 1-4 blocks More than 4 blocks
How far do you live from your nearest bus stop?
Less than 1 block 1-4 blocks More than 4 blocks Do not know
When using fixed route bus or train do you travel?
Independently With assistance Not applicable
Are there any physical barriers or environmental conditions that prevent you
from using public transportation? Yes No
Access ID number
2Disability/Health Condition Information
4 Disability / Health Condition Information
Please describe the disability or health condition which prevents your ability
to travel on a bus or train independently. You may attach more documentation
on a separate page.
Is this a permanent disability or health condition? Yes No
If no, how long do you expect it to prevent you from using fixed route buses
or trains? Week(s) Month(s)
5 Mobility Devices / Aids
Do you require assistance when traveling on the bus or train? Yes No
Sometimes Not applicable
Do you use a service animal? Yes No
What function is it trained to perform?
What is your primary mobility device/aid? (If applicable)
Powered wheelchair Manual wheelchair White cane
Walker Cane Portable oxygen
Brace Prosthesis
Crutches Powered scooter
Other:
Access ID number
3Mobility Devices / Aids (cont.)
What is your secondary mobility device/aid? (If applicable)
Powered wheelchair Manual wheelchair White cane
Walker Cane Portable oxygen
Brace Prosthesis
Crutches Powered scooter
Other:
You will be assessed with the primary mobility device/aid that you bring to the
eligibility center at the time of your appointment. If you change your mobility
device following your evaluation, you may be required to return for a new
evaluation in your new device. Use of a different mobility device may change
your functional ability to use accessible fixed route transit.
IMPORTANT: Most of the accessible vehicles in our fleet are designed to
accommodate a mobility device no larger than 30 inches wide by 48 inches
long and/or weighing with its passenger up to 600 pounds. While we make
all reasonable efforts to accommodate our riders, if your mobility device is
larger than this, we may be unable to transport you either because it would
damage the vehicle or to do so would impose an unreasonable safety hazard.
6 Healthcare Professional Contact Information
Please provide the contact information of your treating healthcare professional
who is familiar with your condition and, if needed, could be contacted for
clarifying information.
The following licensed healthcare professionals are authorized to provide
clarifying information:
> Physician (MD or DO) > Registered nurse > Psychologist
> Psychiatrist > Ophthalmologist > Optometrist
> Physical therapist > Occupational therapist
> Other licensed provider familiar with your condition
Access ID number
4Healthcare Professional Contact Information (cont.)
Healthcare professional’s name Specialization
Institution/facility/agency name
Street address Suite number
City State Zip
Primary phone number Alternate phone number
Fax number Email
7 Certification and Authorization for Release of Information
I hereby certify that, to the best of my knowledge, the information given in this
application is correct. I authorize my healthcare professional to release any and
all information about my disability or health condition and its effects on my
functional ability to travel. I understand that all medical information will be kept
strictly confidential. I agree to undergo an in person assessment of my functional
abilities and limitations for the purpose of making a determination regarding my
eligibility for ADA paratransit service.
Print name Signature Date
Access ID number
58 Person That is Authorized to Complete This Form on Behalf
of the Applicant (optional)
Name Relationship to applicant
Primary phone number Alternate phone number
Referring agency (if applicable)
Signature of person, other than applicant, completing form Date
Access ID number
6Access Eligibility Center
20-0362 ©2020 Access Services
5747 Rickenbacker Rd
Commerce, CA 90040
Application is here.
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